CMS Reports OPPS Hospital Claim Issues

CMS Reports OPPS Hospital Claim Issues

If your accounts receivables are higher than expected in first quarter 2017, remember the old adage: If it’s too good to be true, it probably is.

Due to errors in the Medicare Claims Processing System, some Outpatient Prospective Payment System (OPPS) hospital claims with dates of service on or after January 1, 2017, may have been overpaid. Claims with the following CPT® codes may be affected: 0253T, 0335T, 24361, 25420, 25444, 25445, 27442, 27871, 28715, 28730, 37229, 43266, 45389, 62360, 64580, 69717, and 75898.

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In addition, eight Comprehensive Ambulatory Payment Classification (APC) Complexity Adjustment pairs were incorrectly omitted from the claims processing system:

Primary Code            Code 2                      Complexity-Adjusted APC

28300                          27698                          5115

28300                          28306                          5115

33208                          C9600                         5224

36902                          36908                          5193

36903                          36908                          5194

36904                          36908                          5193

36905                          36908                          5194

49653                          49650                          5362

A correction for these issues will be implemented on April 3, reports the Centers for Medicare & Medicaid Services (CMS) in the January 19, 2017, MLN Connects. Medicare administrative contractors will automatically reprocess impacted claims; providers do not need to take any action.

NCCI Edits for Institutional and Physician Claims

National Correct Coding Initiative (NCCI) edit updates for institutional claims have regularly been implemented one quarter behind the physician claim NCCI edits due to systems issues. As a result, some physician single-quarter-only edits were not implemented for institutional claims. Starting April 3, CMS will apply the same physician NCCI edits to institutional claims, including the single-quarter-only edits.

Source: MLN Connects, January 19, 2017

Renee Dustman

Renee Dustman

Executive Editor at AAPC
Renee Dustman, BS, MACRA Proficient, is an executive editor at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. She has more than 20 years experience in print production and content management, and has worked in a variety of capacities for several publications.
Renee Dustman

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Renee Dustman, BS, MACRA Proficient, is an executive editor at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. She has more than 20 years experience in print production and content management, and has worked in a variety of capacities for several publications.

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